Northern Ireland Dental Levy Fund Opt-out Instruction

Details of Dentist wishing to opt-out
First Name*
Surname*
Main Practice Address*
Address Postcode
HSCNI Email Address*
DS Number(s) to be opted out*

Click the plus button to add more that one DS Number to be opted out (please note, only DS Numbers relating to the individual dentist will be actioned)
Consent*
I am a registered dental practitioner having entered into an agreement to provide General Dental Services under the GDS Regulations 1993 and subsequent amending and superseding legislation ; do hereby authorise and request the Business Services Organisation to cease collecting the Dental Levy at a rate of £1 per £1000 gross fees from my monthly schedule.
This request will be actioned within the monthly payment schedule in which it is received

Details of Dentist wishing to opt-out